Green Mtn PNYNE Campout Online Sign UP
Green Mountain Getaway Camp-out Thurs. AUG 7- Sat, Aug 9 Lake Elmore State Park, Elmore, VT This campout is open to unaccompanied youth age 13 and up. Only 25 spots! Sign up today!
hosted by Barre VT OPC Questions? email olivia@copcvt.org
Name of person attending
First Name
Last Name
cell phone number of participant
Please enter a valid phone number.
home church
Email of participant
example@example.com
Parent(s) name(s) if minor - under age 18
Parent phone number as emergency contact
Additional phone number for emergency contact, [optional]
Age at the time of the retreat. Under age 13 need an accompanying adult.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Describe any allergies or health conditions the camp leaders should know about
I have the following tent or camping equipment available to bring [don't bring unless Olivia asks for it]
Anything additional to mention -- special schedule or arrival/departure needs, need a ride, afraid of the dark, etc. !!! I will contact you re special issues.
Suggested donation is 40 for first child, 20 for any additional family members. Chaperones [over age 18] are free but will be contacted for further screening and responsibility list. Pick your payment choice:
Cash [exact change please] or check made out to Covenant OPC
paypal to olivia@copcvt.org.
chaperone -- no charge
Thanks for reading and signing the following language from the church insurance policy: I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association. [EVERYONE NEEDS TO SIGN. UNDER AGE 18, THE PARENT NEEDS TO SIGN FOR THE TEEN]
Is participant covered by personal/family medical insurance
yes
no
If yes, name of insurer and policy number
Submit this form to Olivia
Should be Empty: